Cirrhosis is scarring of the liver as a result of continuous, long-term liver damage. Scar tissue replaces healthy tissue in the liver and prevents the liver from working properly.

The damage caused by cirrhosis is permanent and can't be reversed. Cirrhosis progresses slowly, over many years, gradually causing your liver to stop functioning. This is called liver failure.

Every year, around 1,000 people in the UK die from cirrhosis. Around 700 people need to have a liver transplant to survive. The number of people with cirrhosis is increasing.

The signs of cirrhosis

There are very few symptoms in the early stages of cirrhosis. However, as your liver loses its ability to function properly, you're likely to experience a loss of appetite, nausea and very itchy skin.

In the later stages, symptoms can include jaundice (yellowing of the skin and whites of the eyes), vomiting blood, dark, tarry-looking stools and a build-up of fluid in the legs and abdomen (oedema).

Read more about the symptoms of cirrhosis.

When to see your GP

As cirrhosis doesn't have many obvious symptoms during the early stages, it's often picked up during tests for an unrelated illness.

See your GP as soon as possible if you have any of the following symptoms:

• fever and shivering
• shortness of breath
• vomiting blood
• very dark or black, tarry stools (faeces)
• periods of confusion or drowsiness

Read more about how cirrhosis is diagnosed.

How does cirrhosis happen?

The two most common causes of cirrhosis in the UK are drinking too much alcohol (alcohol misuse) and becoming infected with the hepatitis C virus.

Less common causes include hepatitis B infection, inherited liver diseases, such as haemochromatosis, and a condition called non-alcoholic steatohepatitis (NASH).

Read more about the causes of cirrhosis.

Treating cirrhosis

Cirrhosis can't be cured. But it's possible to manage the symptoms and any complications witt treatment, and prevent the condition from getting worse.

Treating underlying diseases that may be the cause, such as hepatitis, will also stop the cirrhosis from getting worse.

You may be advised to cut down or stop drinking alcohol or to lose weight if you're overweight. A wide range of alcohol support services are available.

In its worst stage, the scarring caused by cirrhosis can make your liver stop functioning. In this case, a liver transplant is the only treatment option.

Read more about treating cirrhosis.

Preventing cirrhosis

Not exceeding recommended limits for alcohol consumption is the best way of preventing alcohol-related cirrhosis.

Men should drink no more than 3-4 units of alcohol a day. Women should drink no more than 2-3 units a day.

Hepatitis B and C are infectious conditions that can be caught through having unprotected sex or by sharing needles to inject drugs. Using a condom during sex and avoiding injecting drugs will reduce your risk of developing hepatitis B and C.

You can be vaccinated against hepatitis B but there is currently no vaccine for hepatitis C.

People who were born in areas of the world where hepatitis B and C are widespread, such as parts of South Asia and Africa, need to be screened for hepatitis as early treatment can help prevent the onset of cirrhosis.

Read more about preventing cirrhosis.

There are very few symptoms during the early stages of cirrhosis. As healthy liver tissue is destroyed and scar tissue builds up, the liver loses its ability to function properly and more symptoms will appear.

As cirrhosis progresses, it causes your liver to swell. Your liver then begins to shrink as scar tissue replaces healthy tissue. As your liver function weakens, you may have some of the following symptoms:

• tiredness and weakness
• loss of appetite
• weight loss
• feeling sick
• very itchy skin
• tenderness or pain around the liver
• tiny red lines (blood capillaries) on the skin above waist level
• jaundice (see below)
• a tendency to bleed and bruise more easily, such as frequent nosebleeds or bleeding gums
• hair loss 
• fever and shivering attacks – because you're more prone to infections
• oedema – a build-up of fluid in the legs, ankles and feet
• ascites – a build-up of fluid in your abdomen, which can make you look heavily pregnant

Jaundice is the yellowing of the skin and the whites of the eyes. It occurs either as a result of a blockage in your bile duct (the tube that transfers bile from the liver to the gallbladder). Or it results from liver damage, which means that the liver is unable to process a yellow substance in your blood called bilirubin (a by-product of red blood cells).

You may notice changes in your personality due to toxins in your bloodstream that affect your brain. You may also have problems sleeping (insomnia), memory loss, confusion and difficulty concentrating (encephalopathy).

Late-stage symptoms

In the later stages of cirrhosis, you may vomit blood or have tarry, black stools. This is because blood can't flow through the liver properly, which causes an increase in blood pressure in the vein that carries blood from the gut to the liver (portal vein).

The increase in blood pressure forces blood through smaller, fragile vessels that line your stomach and gullet (varices). These can burst under high blood pressure, leading to internal bleeding, which is visible in vomit and/or stools.

Read more about how swollen varices are treated.

There are different causes of cirrhosis, but the most common causes in the UK are drinking excessive amounts of alcohol and getting a hepatitis C infection.

Alcohol-related cirrhosis

The liver breaks down toxins (poisons), such as alcohol, but too much alcohol can damage the cells of the liver and cause it to scar. Men who drink more than 21 units of alcohol a week and women who drink more than 14 units of alcohol a week are considered to be drinking too much. 

Calculate the number of units you drink.

If you're a heavy drinker, your chances of developing cirrhosis are increased. However, it's important to realise that cirrhosis of the liver isn't just a condition that affects people who are dependent on alcohol (alcoholics). If you're a heavy social drinker, you can also develop cirrhosis.

Alcohol-related cirrhosis usually develops after 10 or more years of heavy drinking. Some people are more susceptible to liver cell damage than others. The reasons for this are unknown.

Women who drink heavily are more susceptible to liver damage than men, partly because of their different body size and build.

People who drink excessively and continue to drink heavily develop cirrhosis in three separate stages. These are described below.

• The first stage of alcohol-related liver disease is known as ‘fatty liver’, which almost all excessive drinkers develop. It is a side effect of the liver breaking alcohol down. It disappears when you drink less.
• The second stage of alcohol-related liver disease is alcoholic hepatitis. Around 20-30% of people who continue to drink heavily develop alcoholic hepatitis. During this stage, the liver becomes inflamed. If alcoholic hepatitis deteriorates into its most extreme form (liver failure) it can lead to death.
• Around 10% of heavy drinkers go on to develop cirrhosis, which is the third stage of alcohol-related liver disease.

This risk of developing cirrhosis, along with the risk of alcoholic hepatitis, is one of the main reasons the government recommends that men shouldn't regularly drink more than 3-4 units of alcohol a day, and women shouldn't drink more than 2-3 units of alcohol a day.

Hepatitis-related cirrhosis

Hepatitis is an infection that's carried in the blood. It can cause liver damage which, over time, may develop into cirrhosis. It's caused by the hepatitis C virus and is one of the most common causes of cirrhosis in the UK.

Two other forms of the infection, hepatitis B and D, can also cause cirrhosis.

A person who was born in an area of the world with a high prevalence of hepatitis B and C, such as parts of South Asia or Africa, may have acquired one of them in early childhood. In many of these cases, they are unaware of the development of cirrhosis (which can occur slowly over 10-30 years) as they often feel fine until the symptoms of cirrhosis and liver failure develop.

Non-alcoholic steatohepatitis

Non-alcoholic steatohepatitis (NASH) is a severe liver condition that can lead to cirrhosis. As with alcohol-related liver disease, the early stage of NASH is the build-up of excess fat in the liver. This fat is associated with inflammation and scarring, which could lead to cirrhosis.

NASH can develop in people who are obese, have diabetes, have high levels of fat in the blood (high cholesterol) and high blood pressure. Most people with NASH feel well and aren't aware that they have a problem.

Other causes

A number of other conditions and inherited diseases can prevent the liver functioning healthily and can lead to cirrhosis. These include:

• autoimmune liver disease – the immune system usually makes antibodies to attack bacteria and viruses; however, if you have an autoimmune disease, such as autoimmune hepatitis, primary biliary cirrhosis or primary sclerosing cholangitis (PSC), your immune system will make antibodies that attack healthy organs of the body
• some rare, genetic conditions – such as haemochromatosis (a build-up of iron in the liver and other parts of the body) and Wilson's disease (a build-up of copper in the liver and other parts of the body)
• any condition that causes the bile ducts to become blocked – such as cancer of the bile ducts or cancer of the pancreas 
• Budd-Chiari syndrome – caused by blood clots blocking the veins that carry blood from the liver

In less common cases, the use of certain medications, such as amiodarone and methotrexate, can also cause cirrhosis.

Cirrhosis and diabetes

If you have type 2 diabetes and you develop cirrhosis, your diabetes may get worse. This is because cirrhosis can increase your resistance to insulin (a hormone that the body produces to control blood sugar levels). If you have diabetes and you develop cirrhosis, you should discuss the implications with your GP.

There are very few symptoms of cirrhosis during the early stages of the condition. It's often picked up during tests for an unrelated illness.

You should visit your GP as soon as possible if you have any of the following symptoms:

• fever and shivering
• shortness of breath
• vomiting blood
• very dark or black, tar-like stools (faeces)
• periods of confusion or drowsiness

Read more about the symptoms of cirrhosis.

If your GP suspects that you have cirrhosis, they will take your medical history and carry out a physical examination to look for signs of chronic liver disease. If suspected, you'll be referred for a number of tests to confirm the diagnosis.

Tests

You may have any of the tests that are described below.

• A blood test to measure your liver function and the amount of liver damage. The test may measure the levels of the liver enzymes alanine transaminase (ALT) and aspartate aminotransferase (AST) in your blood (these will be raised if you have hepatitis). The blood test may also be used to identify other causes of liver disease, such as viral hepatitis and too much iron or copper in your blood.
• Imaging tests – an ultrasound scan, computerised tomography (CT) scan or a magnetic resonance imaging (MRI) scan may be carried out on your liver. The scans can produce detailed images of your liver and highlight any scarring. Some scans may also measure the stiffness of the liver, which is a good indication of whether your liver is scarred.
• Liver biopsy – a fine needle is inserted into your body (usually between your ribs). A small sample of liver cells is taken and sent to a laboratory to be examined under a microscope. The biopsy is usually carried out under local anaesthetic, as a day case or with an overnight stay in hospital. The outcome of the biopsy will confirm a diagnosis of cirrhosis and may provide more information about the cause.
• Endoscopy – an endoscope is a thin, long, flexible tube with a light and a video camera at one end. It will be passed down your oesophagus (food pipe) and into your stomach. Images of your oesophagus and stomach will be transmitted to an external screen. The doctor will be looking for varices (swollen vessels), which are a sign of cirrhosis.

Grading

There are several different systems for grading cirrhosis according to how serious it is. One system is the Child-Pugh score which, based on your examination and laboratory tests, grades cirrhosis from A (relatively mild) to C (severe).

The way cirrhosis is treated depends on the underlying cause. Cirrhosis can't be cured, but treatment aims to manage the symptoms and any complications, as well as stopping the condition from getting worse.

It's usually not possible to reverse any liver damage that's already occurred.

Stopping cirrhosis getting worse

Ways to stop the cirrhosis from getting worse include:

• taking medication to treat an underlying disease that has caused liver damage. For example, if you have viral hepatitis you may be prescribed interferon. If you have autoimmune hepatitis you may be given steroid-based medication, such as prednisolone or an immunosuppressant such as azathioprine.
• making lifestyle changes – you may be advised to cut down on your alcohol intake or to lose weight if you're overweight or obese. Read more about living with cirrhosis.

Easing symptoms

A number of treatments can ease the symptoms of cirrhosis. They include:

• a low-sodium (salt) diet or water tablets to reduce the amount of fluid in your body
• tablets to reduce high blood pressure in your portal vein (the main vein from the liver) and prevent or treat any infection
• creams to reduce itching

Managing end-stage complications

With advanced cirrhosis, it's only possible to treat the end-stage complications. It's not possible to treat jaundice (yellowing of the skin and the whites of the eyes) because it's simply a sign that your liver isn't working properly.

Swollen varices

If you vomit blood or pass blood in your faeces, you probably have swollen veins in your oesophagus (food pipe). These are known as oesophageal varices. You'll need urgent medical attention, which means seeing your GP or going to the accident and emergency (A&E) department of your nearest hospital immediately.

Certain procedures can help stop the bleeding and reduce the risk of it happening again. Any of the techniques described below may be used to correct the cause of your bleeding.

• Banding – an endoscopy is carried out (a thin, flexible tube is passed down your throat; it has a light and a camera on the end) and a small band is placed around the base of the varices to help control the bleeding.
• Injection sclerotherapy – following an endoscopy, a substance will be injected into the varices to make the blood clot and scar tissue to form, which helps to stop the bleeding.
• A Sengstaken tube with a balloon on the end – this is another option if bleeding can't be stopped using an endoscopy. The tube is passed down your throat into your stomach and the balloon is inflated, putting pressure on the varices and stopping the bleeding. You'll be heavily sedated during the procedure.
• A transjugular intrahepatic portosystemic stent shunt (TIPSS) – this procedure may be used if bleeding can't be controlled using the above methods. A metal tube called a stent is passed across your liver to join two large veins (the portal vein and hepatic vein). This creates a new route for your blood to flow through, therefore relieving the pressure that causes the varices.

Fluid in the abdomen and legs

Ascites (a build-up of fluid around your stomach area) and peripheral oedema (fluid around your legs and ankles) are common complications of advanced cirrhosis. They'll need to be addressed as soon as possible.

You may have 20 to 30 litres of free water in your stomach area (abdomen), which can make it difficult for you to eat and breathe properly. The fluid may also become infected. The main treatments are restricting sodium (salt) in your diet and taking diuretic tablets, such as spironolactone or furosemide.

In severe cases of ascites, tubes may be used to drain the fluid from your abdomen. This will usually be repeated every few weeks. TIPSS can also be used to treat ascites (see above).

Encephalopathy

People with cirrhosis can sometimes develop problems with their brain function (encephalopathy). This occurs because the liver isn't clearing toxins properly.

The brain’s functioning ability can be impaired, causing confusion and drowsiness and, at a later stage, a coma. Treatment may include taking antibiotics and clearing out the bowel with laxatives or enemas.

Bleeding

Cirrhosis can affect the liver's ability to make the blood clot (thicken), leaving you at risk of severe bleeding if you cut yourself. Vitamin K and plasma can be given in medical emergencies to treat episodes of bleeding. You'll need to apply pressure to any cuts that bleed.

Liver transplant

Your liver may stop functioning if it's severely damaged by scarring. In this situation, a liver transplant is the only option. This is a major procedure that involves removing your diseased liver and replacing it with a healthy donor liver. However, there are more people waiting for a transplant than there are donors.

The best way of preventing alcohol-related cirrhosis is to keep within the recommended limits of alcohol consumption. To protect yourself against hepatitis-related cirrhosis, avoid injecting drugs and unprotected sex.

Heavy alcohol consumption is one of the most common causes of cirrhosis of the liver. The recommended limits of alcohol consumption are:

• men – up to 21 units of alcohol a week (3-4 units a day)
• women – up to 14 units of alcohol a week (2-3 units a day)

If you have cirrhosis, you should stop drinking alcohol immediately because it speeds up the rate at which the condition progresses, regardless of the cause.

Read more about alcohol misuse.

Protect yourself from hepatitis

Cirrhosis can be caused by infectious diseases, such as hepatitis B and C. Hepatitis B and C can be caught through having unprotected sex or by sharing needles in order to inject drugs.

Using a condom when having sex will help you to avoid the risk of getting hepatitis, as will avoiding injecting drugs. Anyone who is at risk of getting hepatitis B, such as police officers and social care workers, can be protected by being vaccinated against the condition.

However, there is currently no vaccine for hepatitis C.

People who were born in areas of the world where hepatitis B and C are widespread, such as parts of South Asia and Africa, need to be screened for hepatitis, as early treatment can help prevent the onset of cirrhosis.

Screening patients with cirrhosis

Patients with cirrhosis of the liver (no matter what the cause), are at a small but significantly increased risk of developing a type of liver cancer called hepatocellular carcinoma.

Patients with cirrhosis will be asked by their doctors to have regular screening for this cancer. It involves having an ultrasound of the liver and a blood test (for a tumour marker in the blood called alpha fetoprotein) every six months.

If you have cirrhosis, stop drinking immediately because alcohol increases the rate at which the condition progresses, regardless of the cause.

If you're taking over-the-counter or prescription medications, tell your GP or pharmacist, because the liver processes some medicines.

Diet

One of the symptoms of end-stage liver disease is an abnormal accumulation of fluid in the abdomen, called ascites. If you have ascites, follow a low-sodium (salt) diet of no more than 1000mg per day, or 500mg if possible. This will reduce the amount of fluid in your body.

It's also important to eat a well-balanced diet. You may need extra energy and protein. Cirrhosis causes damage that stops the liver working properly, so it may be unable to store glycogen, the carbohydrate that provides short-term energy. When this happens, the body uses its own muscle tissue to provide energy between meals, which leads to muscle wasting and weakness.

Healthy snacking between meals can top up your calories and protein, which helps to preserve muscles and keep them strong. Improved nourishment will also make you feel better. Try to eat regularly – about every two to three hours.

More information

For more lifestyle advice, go to the British Liver Trust's factsheet on Looking after yourself.